1730193657 NPI number — TRINITY MEDICAL CENTER, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730193657 NPI number — TRINITY MEDICAL CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRINITY MEDICAL CENTER, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730193657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37300 DEQUINDRE RD
Provider Second Line Business Mailing Address:
STE 120
Provider Business Mailing Address City Name:
STERLING HEIGHTS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48310-3591
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-275-0065
Provider Business Mailing Address Fax Number:
586-275-0066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37300 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
STERLING HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48310-3591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-275-0065
Provider Business Practice Location Address Fax Number:
586-275-0066
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AL-MATCHY
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
PETROS
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
586-275-0065

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301070663 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4301070663 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700E027480 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4889519 10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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